President's Commission and the normal accident

This chapter incorporates the major points of an analysis of the accident at Three Mile Island that I prepared in September 1979. In contrast to the findings of the President's Commission (1979), I did not view the accident as the result of operator error, an inept utility, or a negligent Nuclear Regulatory Commission but as a consequence of the complexity and interdependence that characterize the system itself. I argued that the accident was inevitable-that is, that it could not have been prevented, foreseen, or quickly terminated, because it was incomprehensible. It resembled other accidents in nuclear plants and in other high risk, complex and highly interdependent operator-machine systems; none of the accidents were caused by management or operator ineptness or by poor government regulation, though these characteristics existed and should have been expected. I maintained that the accident was normal, because in complex systems there are bound to be multiple faults that cannot be avoided by planning and that operators cannot immediately comprehend